Neurogenic bladder in spinal cord injury

Progress and research trends in neurogenic bladder after spinal cord injury bibliometric analysis based on web of science database: An observational study

Neurogenic bladder (NB) is a significant complication that often occurs after spinal cord injury. It results from urinary dysfunction caused by the injury, disrupting the normal neural control of the bladder and urethra. Symptoms of NB can include urinary frequency, urgency, incontinence, and retention, all of which can greatly impact the quality of life of affected individuals. While there are articles and reviews on NB, fewer specifically address NB following spinal cord injury. This study examined 1095 publications from January 1, 2000, to March 27, 2024, in the Web of Science core database using bibliometric software like VOSviewer, CiteSpace, and Bibliometrics. The analysis revealed an increasing trend in the number of publications, with the United States and China leading in research output. Professor Jeremy B. Myers from the University of Utah had the highest number of publications, while the University of Michigan and the University of Pittsburgh were the institutions with the most publications. The journal Neurourology and Urodynamics had the highest number of articles, and common keywords included management, quality of life, and dysfunction, highlighting key areas of focus for scholars.

Bilateral subconjunctival haemorrhage in spinal cord injury: a case report

Neurogenic lower urinary tract dysfunction is a common symptom after spinal cord injury. Here, the case of a 45-year-old male patient who was treated with indwelling urinary catheter during spinal surgery for a fall fracture injury of the T12 thoracic vertebra, associated with decreased muscle strength of both lower extremities, is described. During hospitalization in the rehabilitation department, conventional anticoagulation therapy was administered, and the urinary catheter was removed with the patient urinating by increasing abdominal pressure. At 8 days following urinary catheter removal, the patient was found to have a slight subconjunctival haemorrhage of the left eye, which gradually developed into massive subconjunctival haemorrhage in both eyes. After re-indwelling the urinary catheter, the bilateral subconjunctival haemorrhage gradually improved. No abnormal indicators were found during re-examination of coagulation function and platelet count, and the results of ophthalmological examination were normal. For patients with neurogenic bladder dysfunction associated with spinal cord injury, the risk of bleeding during the anticoagulation period should be carefully assessed to eliminate possible underlying bleeding risk factors (including past medical history and appropriate use of anticoagulant drugs) when considering spontaneous urination through the mode of abdominal pressure.

Molecular Characterization of Non-Neurogenic and Neurogenic Lower Urinary Tract Dysfunction (LUTD) in SCI-Induced and Partial Bladder Outlet Obstruction Mouse Models

We examined bladder function following spinal cord injury (SCI) by repeated urodynamic investigation (UDI), including external urethral sphincter (EUS) electromyography (EMG) in awake restrained mice and correlated micturition parameters to gene expression and morphological changes in the bladder. A partial bladder outlet obstruction (pBOO) model was used for comparison to elucidate both the common and specific features of obstructive and neurogenic lower urinary tract dysfunction (LUTD). Thirty female C57Bl/6J mice in each group received an implanted bladder catheter with additional electrodes placed next to the EUS in the SCI group. UDI assessments were performed weekly for 7 weeks (pBOO group) or 8 weeks (SCI group), after which bladders were harvested for histological and transcriptome analysis. SCI mice developed detrusor sphincter dyssynergia (DSD) one week after injury with high-pressure oscillations and a significantly increased maximal bladder pressure P_max and were unable to void spontaneously during the whole observation period. They showed an increased bladder-to-bodyweight ratio, bladder fibrosis, and transcriptome changes indicative of extracellular matrix remodeling and alterations of neuronal signaling and muscle contraction. In contrast, pBOO led to a significantly increased P_max after one week, which normalized at later time points. Increased bladder-to-bodyweight ratio and pronounced gene expression changes involving immune and inflammatory pathways were observed 7 weeks after pBOO. Comparative transcriptome analysis of SCI and pBOO bladders revealed the activation of Wnt and TGF-beta signaling in both the neurogenic and obstructive LUTD and highlighted FGF2 as a major upregulated transcription factor during organ remodeling. We conclude that SCI-induced DSD in mice leads to profound changes in neuronal signaling and muscle contractility, leading to bladder fibrosis. In a similar time frame, significant bladder remodeling following pBOO allowed for functional compensation, preserving normal micturition parameters.

Long-Term Surveillance and Management of Urological Complications in Chronic Spinal Cord-Injured Patients

Bladder dysfunction is a common complication after chronic spinal cord injury (SCI). Patients may experience renal function loss, urinary tract infection (UTI), urolithiasis, bladder cancer, and even life-threatening events such as severe sepsis or renal failure. Suitable patient care may prevent UTI and urinary incontinence, decrease medication use, and preserve renal function. As the primary goal is to preserve renal function, management should be focused on facilitating bladder drainage, the avoidance of UTI, and the maintenance of a low intravesical pressure for continence and complete bladder emptying. Currently, several bladder management options are available to SCI patients: (1) reflex voiding; (2) clean intermittent catheterization; (3) indwelling catheterization. The target organ may be the bladder or the bladder outlet. The purposes of intervention include the following: (1) increasing bladder capacity and/or decreasing intravesical pressure; (2) increasing bladder outlet resistance; (3) decreasing bladder outlet resistance; (4) producing detrusor contractility; (5) urinary diversion. Different bladder management methods and interventions may have different results depending on the patient's lower urinary tract dysfunction. This review aims to report the current management options for long-term bladder dysfunction in chronic SCI patients. Furthermore, we summarize the most suitable care plans for improving the clinical outcome of SCI patients.

Bladder Management Strategies for Urological Complications in Patients with Chronic Spinal Cord Injury

Neurogenic lower urinary tract dysfunction, common in patients with chronic spinal cord injury, inevitably results in urological complications. To address neurogenic lower urinary tract dysfunction after spinal cord injury, proper and adequate bladder management is important in spinal cord injury rehabilitation, with the goal and priorities of the protection of upper urinary tract function, maintaining continence, preserving lower urinary tract function, improvement of SCI patients' quality of life, achieving compatibility with patients' lifestyles, and decreasing urological complications. This concise review aims to help urologists address neurogenic lower urinary tract dysfunction by focusing on the risks of long-term urological complications and the effects of different bladder management strategies on these complications based on scientifically supported knowledge.

Satisfaction with Surgical Procedures and Bladder Management of Chronic Spinal Cord Injured Patients with Voiding Dysfunction Who Desire Spontaneous Voiding

We aimed to investigate treatment outcome and satisfaction with bladder outlet surgeries and bladder management in patients with spinal cord injury (SCI), voiding dysfunction, and to seek a spontaneous voiding or reflex voiding program. A total of 261 patients were included in this retrospective study. The mean age at surgical procedure was 49.2 ± 15.9 years; the median follow-up period was 11 (IQR 6, 17) years; 119 received a urethral Botox injection, 41 underwent transurethral incision of the bladder neck (TUI-BN), 77 underwent transurethral incision or resection of the prostate (TUI-P or TUR-P), and 24 had an external sphincterotomy. Satisfactory surgical outcome was reported by 80.5% of patients undergoing TUI-BN, 70.8% undergoing external sphincterotomy, 64.9% receiving TUI-P or TUR-P, and 59.7% receiving the urethral Botox injection. Persistent dysuria was the most common reason for dissatisfaction after the urethral Botox injection (73.1%) and TUI-BN (58.5%). Recurrent urinary tract infection continued in most patients after any type of surgery (all >75%). Most patients with SCI were satisfied with their initial bladder outlet operation in facilitating spontaneous voiding. However, repeat, or multiple surgical interventions were needed in 65.5% of SCI patients to achieve satisfactory voiding. A correct diagnosis is very important before every intervention and bladder management to reach the best satisfaction. VUDS is suggested before surgical procedures to ensure efficacy, even in patients with the same level of SCI.

Diagnosis and treatment of neurogenic bladder secondary to aortic dissection: A 8-year retrospective study at a single center

PURPOSE

To review the characteristics of the neurogenic lower urinary tract dysfunction (NLUTD) secondary to aortic dissection (AD), analyze the clinical features, and discuss the treatment options.

METHODS

Ten individuals complaining of lower urinary tract syndrome following AD were enrolled in this study. Clinical characteristics, urological and neurological symptoms/signs, imaging examination, and intervention were reviewed. Liao's comprehensive classification system was used to precisely assess the lower and upper urinary dysfunction.

RESULTS

The urinary symptoms can be varied, including dysuria, incontinence, and frequency. Individuals were divided into the detrusor overactivity (DO) and detrusor underactivity (DU) subgroups. Continence, impaired upper urinary tract functions (renal insufficiency, vesicoureteral reflux, upper urinary tract dilatation, and lower urinary tract functions (DO and/or detrusor external sphincter dyssynergia/detrusor bladder neck dyssynergia, DU, low bladder capacity, and compliance) were examined using video-urodynamics. The principle of treatment is "low-pressure bladder storage with complete bladder emptying," and close follow-up was recommended due to the volatile course of NLUTD.

CONCLUSIONS

Both cardiovascular surgeons and urologists should pay attention to the occurrence of NLUTD following AD, and determine the most appropriate therapeutic option.

The role of spinal cord tractography in detecting lesions following selective bladder afferent and efferent fibers: A novel method for induction of neurogenic lower urinary tract dysfunction in rabbit

OBJECTIVE

Neurogenic lower urinary tract dysfunction (NLUTD), a challenging disorder, is defined by lack of bladder control due to the abnormalities in neural pathways and can be classified based on the location of lesions within the nervous system, thus investigating the neural pathways can help us to know the site of the lesion and specify the class of the NLUTD. Diffusion Tensor Imaging (DTI) tractography, a noninvasive advanced imaging method, is capable of detecting central nervous system pathologies, even if routine magnetic resonance imaging shows no abnormality. Accordingly, tractography is an ideal technique to evaluate patients with NLUTD and visualize the pathology site within the spine. This study aimed to introduce a novel method of spinal cord injury (SCI) to establish NLUTD in the rabbit and to investigate the potential of tractography in tracing neural tracts of the spinal cord in an induced NLUTD animal model.

MATERIALS AND METHODS

An animal model of NLUTD was induced through cauterization of the spinal cord at the level T12-L1 in 12 rabbits. Then rabbits were assessed via DTI, urodynamic studies (UDS), voiding cystourethrogram (VCUG), and pathology assessments using antineurofilament 200 (NF200) antibody, anti-S100, anti-Smooth Muscle Actin, anti-Myogenin, and anti-MyoD1.

RESULTS

The tractography visualized lesions within spinal cord fibers. DTI parameters including fractional anisotropy (FA) value and tract density were significantly decreased (FA: p-value = 0.01, Tract density: p-value = 0.05) after injury. The mean diffusivity (MD) was insignificantly increased compared to before the injury. Also, the results of UDS and pathology assessments corroborated that applying SCI and the establishment of the NLUTD model was completely successful.

CONCLUSION

In the present study, we investigated the auxiliary role of tractography in detecting the spinal cord lesions in the novel established rabbit model of NLUTD. The introduced method of NLUTD induction was without the leg's neurological deficit, easily applicable, low-cost, and was accompanied by minimal surgical preparation and a satisfactory survival rate in comparison with other SCI animal models.

Prevalence of bacteriuria in cats with neurogenic bladder

Urinary tract infections are defined as the adherence, multiplication, and persistence of an infectious agent within the urogenital system, causing an associated inflammatory response and clinical signs; instead, the presence of bacteria in urine as determined by positive bacterial culture (PUC) from a properly collected urine specimen, in the absence of clinical signs, is defined subclinical bacteriuria. Limited information on the prevalence of PUC in spinal cord injury cats affected by neurogenic bladder (NB) is available. On contrary, in NB dogs and humans the prevalence of bacteriuria is well documented. Moreover, while in humans information about bacteriemia associated with NB is already available, this aspect has never been studied in NB cats. The aim of this prospective study was to determine the prevalence of PUC in cats with NB, compared to animals affected by chronic kidney disease (CKD) and healthy cats. Furthermore, the prevalence of bacteriemia in cats with NB was evaluated. Fifty-one cats met the inclusion criteria: 12 cats were affected by NB, 22 had CKD and 17 were healthy. The prevalence of PUC was 58.33% and 18% in NB and CKD cat populations, respectively. All blood cultures were negative. The incomplete bladder emptying and the decreased resistance in the bladder wall could be considered predisposing elements to PUC in the NB feline population. The results of this study highlight, for the first time, an high prevalence of PUC in cats affected by NB, which was not found to be associated with bacteriemia.

Urinary system complications and long-term treatment compliance in chronic traumatic spinal cord injury patients with neurogenic lower urinary tract dysfunction

Objectives

The aim of this study was to evaluate upper and lower urinary tract complications and the compliance of long-term treatment in patients with spinal cord injury (SCI) by urodynamic examination.

Patients and methods

Between January 1997 and May 2007, a total of 89 patients with SCI (79 males, 19 females; mean age: 39.8±12.2 years; range, 19 to 72 years) who were admitted to physical medicine and rehabilitation clinic were retrospectively analyzed. Demographic, neurological, and urodynamic data of the patients with the diagnosis of neurogenic lower urinary tract dysfunction (NLUTD) in their initial urodynamic examination and without regular follow-up were recorded.

Results

The mean time to the first urodynamic examination was 8.6±5.4 months. Sixty-seven patients who had neurogenic detrusor overactivity (NDO) in their first urodynamic tests were recommended anticholinergics. Clean intermittent catheterization (CIC) was recommended after initial urodynamic examination in all patients. Thirty-nine patients of 67 who had NDO were taking medications, while 28 were not. In the patients who continued anticholinergic treatment, bladder capacity was found to statistically significantly increase, compared to the initial measurement values and detrusor pressures significantly decreased (p<0.001). The compliance rate with CIC and anticholinergic treatment was 79.8% and 58.2%, respectively. Sixteen of the patients had calculus in the urinary system. Forty-two patients had infections more than once a year and used antibiotics.

Conclusion

Neurogenic bladder should be evaluated at the beginning of SCI and, then, followed on a regular basis. Urodynamic tests should be performed immediately after spinal shock and can be repeated, as indicated.

Remodeling of extracellular matrix in the urinary bladder of paraplegic rats results in increased compliance and delayed fiber recruitment 16 weeks after spinal cord injury

The ability of the urinary bladder to maintain low intravesical pressures while storing urine is key in ensuring proper organ function and highlights the key role that tissue mechanics plays in the lower urinary tract. Loss of supraspinal neuronal connections to the bladder after spinal cord injury can lead to remodeling of the structure of the bladder wall, which may alter its mechanical characteristics. In this study, we investigate if the morphology and mechanical properties of the bladder extracellular matrix are altered in rats 16 weeks after spinal cord injury as compared to animals who underwent sham surgery. We measured and quantified the changes in bladder geometry and mechanical behavior using histological analysis, tensile testing, and constitutive modeling. Our results suggest bladder compliance is increased in paraplegic animals 16 weeks post-injury. Furthermore, constitutive modeling showed that increased distensibility was driven by an increase in collagen fiber waviness, which altered the distribution of fiber recruitment during loading. STATEMENT OF SIGNIFICANCE: The ability of the urinary bladder to store urine under low pressure is key in ensuring proper organ function. This highlights the important role that mechanics plays in the lower urinary tract. Loss of control of neurologic connection to the bladder from spinal cord injury can lead to changes of the structure of the bladder wall, resulting in altered mechanical characteristics. We found that the bladder wall's microstructure in rats 16 weeks after spinal cord injury is more compliant than in healthy animals. This is significant since it is the longest time post-injury analyzed, to date. Understanding the extreme remodeling capabilities of the bladder in pathological conditions is key to inform new possible therapies.

Urodynamic effect of vibegron on neurogenic lower urinary tract dysfunction in individuals with spinal cord injury: A retrospective study

STUDY DESIGN

A Retrospective study.

OBJECTIVES

To investigate the effects of vibegron on urodynamic parameters of individuals with spinal cord injury (SCI).

SETTING

The National Hospital Organization, Murayama Medical Center, Japan.

METHODS

We retrospectively analyzed the urodynamic parameters of 31 individuals with SCI within one year after injury, who were diagnosed with neurogenic lower urinary tract dysfunction (NLUTD) according to a urodynamic study (UDS), and prescribed vibegron between December 2018 and December 2020. Treatment criteria were as follows: cystometric capacity of <200 mL, bladder compliance of <20 mL/cmH₂O, and/or presence of detrusor overactivity in the first UDS. We compared urodynamic data before and after vibegron treatment.

RESULTS

Vibegron administration increased the maximum cystometric capacity (MCC) (median, from 185.0 to 340.0 mL, P = 0.001), bladder compliance (median, from 8.3 to 20.0 mL/cmH₂O, P < 0.001).

CONCLUSION

Vibegron therapy improved the bladder capacity and bladder compliance of individuals with NLUTD and SCI.

Spinal cord injury and neurogenic lower urinary tract dysfunction: what do we know and where are we going?

One of the well reported but difficult to manage symptoms of spinal cord injury (SCI) is neurogenic lower urinary tract dysfunction (NLUTD). The type of NLUTD is variable based on location and extent of injury. SCI affects more males and NLUTD is especially debilitating for men with incomplete injury. This review summarizes the anatomical basis of NLUTD in SCI and discusses current diagnostic and management strategies that are being utilized clinically. The last two sections address new innovations and emerging discoveries with the goal of increasing scientific interest in improving treatment options for people with SCI. Areas warranting further investigation are pinpointed to address current gaps in knowledge and/or appropriate technology.

Clean intermittent catheterization in long-term management of neurogenic bladder in spinal cord injury: Patient perspective and experiences

OBJECTIVES

Bladder dysfunction due to spinal cord injury has a significant impact on the overall health and quality of life of an individual. Clean intermittent catheterization is the gold standard for bladder management and is recommended due to having the lowest complication rate. Transitions from intermittent catheterization to other less optimal strategies, such as indwelling catheter, are quite common. However, the research documenting patient perspectives, and epidemiological and demographic factors related to such transition is limited.

METHODS

Data from patients with spinal cord injury rehabilitated with clean intermittent catheterization were collected. Demographic and epidemiological details of the patients were documented from the inpatient records. Appropriate statistical tests were applied to the values.

RESULTS

Among the 45 participants, 68.89% continued clean intermittent catheterization. In those who discontinued clean intermittent catheterization, the median duration of practicing clean intermittent catheterization was 3.5 months. The commonest difficulty among compliant patients was carrying out clean intermittent catheterization in outdoor environments due to the unavailability of toilet facilities. Urinary tract infection was the most common (17.78%) complication noted. Dependence (20.00%) was a major procedural difficulty followed by pain. Adaptations to remain continent in special conditions were diapers and condom catheters. The duration of clean intermittent catheterization practiced influenced discontinuation of clean intermittent catheterization. With an increase in the duration of clean intermittent catheterization practiced after discharge, the risk of discontinuation of clean intermittent catheterization decreased with an adjusted odds ratio of 0.773 (95% confidence interval 0.609-0.982).

CONCLUSIONS

People with spinal cord injury have many challenging issues in the regulation of bladder function at their level inclusive of procedural difficulties, environmental barriers and medical complications, and understanding of which will help to establish a comprehensive and a holistic program to provide remote/community care.

Protein Considerations for Athletes With a Spinal Cord Injury

Athlete participation in the Paralympic games is steadily increasing; prompting research focused on the unique needs of this population. While the Paralympic Games includes a diversity of athletes, athletes with a spinal cord injury (PARA-SCI) represent a subgroup that requires specialized recommendations. Nutritional guidelines designed to optimize performance, in the context of the neurological impairments, are required. This narrative review summarizes the current literature regarding the importance of dietary protein for optimal health and performance. Factors with the potential to affect protein needs in PARA-SCI including loss of active muscle mass, reduced energy expenditure, and secondary complications are examined in detail. Furthermore, we analyze protein intakes in PARA-SCI from the available research to provide context around current practices and trends. In conclusion, we make the case that protein recommendations for able-bodied athletes may not be directly transferable to PARA-SCI. Consequently, PARA-SCI need their own guidelines to maximize performance and ensure long-term health.

Clinical and genetic characteristics of concomitant Mucopolysaccharidosis type IVA and neurogenic bladder in children: two case reports and literature review

Background

Mucopolysaccharidosis IVA (MPS IVA; Morquio A syndrome) is a rare autosomal recessive lysosomal storage disorder. Up to now, reports on the clinical characteristics of MPS IVA mainly focused on patients with progressive bone dysplasia and multiple organ damage, while the effects of this disorder on neurogenic bladder have not been reported. Therefore, the aim of the present study is to report two cases of nocturnal enuresis finally diagnosed as neurogenic bladder in MPS IVA.

Case presentation

Both children were characterized by the presence of pectus carinatum, kyphoscoliosis, nocturnal enuresis, urinary incontinence, normal intelligence, and loss of strength in the legs, diagnosed as neurogenic bladder in association with MPS IVA through the analysis of the clinical characteristics, enzyme activity and genetic testing. In addition, the terminator codon mutation c.1567T > G (p.X523E) and a novel missense mutation c.575A > G (p.E192G) were found in the coding region of the GALNS gene of the 1^st patient, while the missense mutation c.488C > A (p.P163H) was found in the coding region of the GALNS gene of the 2^nd patient.

Conclusions

Neurogenic bladder may occur in patients with MPS IVA after spinal cord injury. It is necessary to screen for the diagnosis of MPS IVA in patients with atypical enuresis and skeletal abnormalities through the analysis of the clinical characteristics, enzyme activity and genetic testing.

Catheter-Related Bladder Discomfort: How Can We Manage It?

The urethral catheter is used in various clinical situations such as diagnosing urologic disease, urine drainage in patients after surgery, and for patients who cannot urinate voluntarily. However, catheters can cause numerous adverse effects, such as catheter-associated infection, obstruction, bladder stones, urethral injury, and catheter-related bladder discomfort (CRBD). CRBD symptoms vary among patients from burning sensation and pain in the suprapubic and penile areas to urinary urgency. CRBD significantly reduces patient quality of life and can lead to several complications. CRBD is caused by catheter-induced bladder irritation due to muscarinic receptor-mediated involuntary contractions of bladder smooth muscle and also can be caused by mechanical stimulus of the urethral catheter. Various pharmacologic studies for managing CRBD, including antimuscarinic and antiepileptic agents and botulinum toxin injections have been reported. If urologists can reduce patients’ CRBD, their quality of life and recovery can improve.

Different types of acupuncture and moxibustion therapy for neurogenic bladder after spinal cord injury: A systematic review and network meta-analysis study protocol

BACKGROUND

The invasive surgical intervention for neurogenic bladder dysfunction (NBD) following spinal cord injury (SCI) involves permanently altering one's body system and carries many surgical related risks and medication side effects are often seen in long term usage of pharmaceutical medications. Therefore, acupuncture and moxibustion therapies have been recommended due to their efficacy, simplicity of operation, cost effectiveness and safety. This protocol is designed for systematic review and network meta-analysis, which will perform comparisons or rankings of efficacy among the currently available acupuncture and moxibustion techniques and provide evidence to guide the best practice in acupuncture and moxibustion treatments of NBD due to SCI.

METHODS/DESIGN

The Cochrane Library, EMBASE, PubMed, Web of Science, CENTRAL, CNKI, The VIP Database, The Wanfang database, CDFD, CMFD will be searched from inception to November 1, 2019. All randomized controlled trials containing eligible interventions(s) and outcome(s) will be included. The quality of included trials will be assessed using the "Risk of bias" tool from the Cochrane Handbook (V.5.1.0). Data analysis will be conducted by using STATA software (Version 13.0). Continuous outcome will be indicated as mean difference (MD) or standard mean difference (SMD), and enumeration data will be presented with odds risk (OR) or relative risk (RR).

RESULTS

This systematic review and network meta-analysis study aims to determine the most effective and safe approach in relieving urinary symptoms, and whether it produces better results in urodynamic examination. And a high-quality ranking of the therapeutic classes will be presented. The report will follow the PRISMA checklist for network meta-analysis. Results of the search strategy and the study selection will be presented in a PRISMA compliant flow chart.

CONCLUSION

This study aims to propose a standard clinical decision-making guideline for acupuncture and moxibustion treatment of NBD after SCI.

Effect of intravesical botulinum toxin injection on symptoms of autonomic dysreflexia in a patient with chronic spinal cord injury: a case report

Context: There are few treatment options for managing autonomic dysreflexia in patients with chronic spinal cord injury (SCI). According to some studies, intravesical botulinum toxin for SCI patients with autonomic dysreflexia has a preventive effect on symptoms of autonomic dysreflexia. However, the usefulness of an intravesical botulinum toxin injection has never been reported for autonomic dysreflexia in an adult patient with chronic cervical SCI, although there has been for one pediatric patient.Findings: A 62-year-old man with chronic cervical SCI had neurogenic bladder due to C6-7 SCI since sustaining a fall in 1980. He presented with an intermittent headache and severe hypertension because of persistent autonomic dysreflexia. His symptoms did not improve with conservative management, and he could not undergo an operation to resect the lung cancer because of his uncontrolled blood pressure. To control his fluctuating blood pressure, he was taken to an operating room to receive an intravesical botulinum toxin injection for refractory bladder spasms. Subsequently, his blood pressure was controlled, and then the lung mass could be surgically removed. His improved condition lasted for more than 6 months.Conclusion: This case suggests that botulinum toxin is a logical treatment option for autonomic dysreflexia as well as neurogenic detrusor overactivity in patients with chronic SCI. Dedicated research is warranted to assess the efficacy of an intravesical botulinum toxin injection, as it was used successfully to stop the symptoms of autonomic dysreflexia in our patient.

Effectiveness of rehabilitation training combined acupuncture for the treatment of neurogenic bladder secondary to spinal cord injury

BACKGROUND

This study will aim to assess the effectiveness of the rehabilitation training (RT) combined acupuncture for the treatment of patients with neurogenic bladder (NB) secondary to the spinal cord injury (SCI).

METHODS

We will conduct a comprehensive literature search from the following databases from the inceptions to the present with no language limitation: PUBMED, EMBASE, Cochrane Library, SinoMed, Web of Science, Allied and Complementary Medicine Database, VIP, WANGFANG, Chinese Biomedical Literature Database, and China National Knowledge Infrastructure. Additionally, we will also search gray literature, including dissertations and conference proceedings. RevMan V.5.3 software will be used for the study selection, assessment of bias of bias, and data synthesis.

RESULTS

This study will synthesize the available evidence of RT combined with acupuncture for NB secondary to SCI, including episodes of urinary incontinence, urinary retention, urinary tract infection, bladder overactivity, quality of life, and adverse events.

CONCLUSION

This study will determine whether RT combined acupuncture is an effective and safety therapy for NB secondary to SCI.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42019146127.

Emerging Encapsulation Technologies for Long-Term Reliability of Microfabricated Implantable Devices

The development of reliable long-term encapsulation technologies for implantable biomedical devices is of paramount importance for the safe and stable operation of implants in the body over a period of several decades. Conventional technologies based on titanium or ceramic packaging, however, are not suitable for encapsulating microfabricated devices due to their limited scalability, incompatibility with microfabrication processes, and difficulties with miniaturization. A variety of emerging materials have been proposed for encapsulation of microfabricated implants, including thin-film inorganic coatings of Al2O3, HfO2, SiO2, SiC, and diamond, as well as organic polymers of polyimide, parylene, liquid crystal polymer, silicone elastomer, SU-8, and cyclic olefin copolymer. While none of these materials have yet been proven to be as hermetic as conventional metal packages nor widely used in regulatory approved devices for chronic implantation, a number of studies have demonstrated promising outcomes on their long-term encapsulation performance through a multitude of fabrication and testing methodologies. The present review article aims to provide a comprehensive, up-to-date overview of the long-term encapsulation performance of these emerging materials with a specific focus on publications that have quantitatively estimated the lifetime of encapsulation technologies in aqueous environments.

Effect of Selenium Nanoparticle Supplementation on Tissue Inflammation, Blood Cell Count, and IGF-1 Levels in Spinal Cord Injury-Induced Rats

Selenium is known to be a neuroprotective agent in respect to a number of neuronal diseases and pain. The aim of this study was to evaluate the neuroprotective effect of the oral administration of selenium nanoparticles in rats with spinal cord injury (SCI). Forty adult female rats were randomly assigned to two equal groups as experimental and control. Under general inhalation anesthesia, in both groups, SCI was created, at the T9-10 level of the column. On the third day after the operation, a supplement of selenium nanoparticle was administered to the experimental group at 0.2 mg/kg per day. The histology of the site of injury, IGF-1 serum concentrations, and changes in the white blood cells were examined in both groups at different pre-surgical and post-surgical times. The results of the current study showed a significant decrease in the total white blood cells, including lymphocyte, neutrophil, and monocyte in the experimental group compared to the control group. Histological evaluation showed that the inflammatory responses reduced significantly in the experimental group compared to the control group. In conclusion, we speculate that the decrease in the number of inflammatory cells after oral administration of the selenium nanoparticles is due to the neuroprotective effects of this nanoparticle.

Rationales for a Urodynamic Study in Patients with Cervical Spondylotic Myelopathy

BACKGROUND

Detrusor sphincter dyssynergia, involuntary detrusor contractions (IDCs), and poor bladder compliance are common urodynamic findings in cervical spondylotic myelopathy (CSM). There is little information regarding the role of a urodynamic study after decompression surgery for CSM.

METHODS

Urodynamic study was performed before and 6 months after decompression of CSM. Japanese Orthopaedic Association score for cervical myelopathy and Neck Disability Index functional score were applied. International Prostate Symptom Score was applied in male patients, and 6-item Urogenital Distress Inventory was applied in female patients.

RESULTS

Mean patient age was 61.3 years. Final follow-up was obtained in 17 of 32 patients. Neurogenic bladder was confirmed in 11 (64.7%) patients, with 7 patients having poor bladder compliance, 3 patients having IDCs, and 6 patients having detrusor sphincter dyssynergia. Poor bladder compliance was normalized in 4 of 7 patients. IDCs disappeared in 2 (phasic IDCs) of 3 patients and improved in 1 (terminal IDC) patient. Detrusor sphincter dyssynergia markedly improved in 4 of 6 patients. Bladder compliance in 17 patients was 45.52 ± 23.71 before decompression surgery and 77.07 ± 39.85 after decompression surgery (P = 0.004). Both Japanese Orthopaedic Association and Neck Disability Index scores improved (P = 0.007 and P = 0.001, respectively). International Prostate Symptom Score and 6-item Urogenital Distress Inventory were not changed 6 months after surgery.

CONCLUSIONS

Neurogenic bladder could be partially controlled in patients with CSM after surgical decompression. The neurogenic component in the urodynamic study findings varied. Depending on the findings, further appropriate urologic treatments after neurologic decompression surgery should be considered.

Effect of Early Sacral Neuromodulation on Bladder Function in a Rat Model of Incomplete Spinal Cord Injury Due to Focal Contusion

OBJECTIVES

Incomplete spinal cord injury (SCI) accounts for two-thirds of all SCIs in clinical practice. Preclinical research on the effect of sacral neuromodulation (SNM) on bladder function, however, has been focused only on animal models of complete SCI. We aimed to evaluate the effect of early SNM on bladder responses in a rat model of incomplete SCI.

MATERIALS AND METHODS

Altogether, 21 female Sprague-Dawley rats were equally assigned to control (CTR), SCI + sham stimulation (SHAM), and SCI + SNM (SNM) groups. In the SHAM and SNM groups, incomplete SCI was created by producing a moderate contusion with an NYU-MASCIS impactor at the T9-T10 level of the spine, with needle electrodes implanted bilaterally into the S2 or S3 sacral foramen. Only SNM group underwent electrical stimulation for 28 days, beginning on day 7 after SCI. Cystometry was performed 35 days after SCI.

RESULTS

Although the interval between voiding contractions was significantly longer in the SHAM group than the CTR group (25.5 ± 1.4 vs. 12.5 ± 1.7 min; p < 0.05), there were no significant differences between the SNM group (16.5 ± 1.5 min) and the CTR group. Maximum voiding contraction pressure did not differ among the groups. The SNM group had a significantly lower frequency (3.5 ± 0.5 vs. 14.6 ± 2.0; p < 0.05) and maximum pressure (11.4 ± 6.2 vs. 21.3 ± 1.8 cmH₂ O; p < 0.05) of nonvoiding contractions than the SHAM group.

CONCLUSIONS

Our results provide experimental evidence that early SNM treatment may prevent or diminish bladder dysfunctions (e.g., detrusor overactivity, abnormal micturition reflex) in a clinical condition of incomplete SCI.

A feasibility study using cadaver: Efficacy and safety of the novel automatic urinary catheterization device

Intermittent catheterization is an effective bladder management strategy for patients with incomplete bladder emptying. For self-catheterization, sufficient hand function in both hands is necessary. We have developed a novel automatic urinary catheterization device to induce self-IC for patients with bladder dysfunction and upper extremity disability. The aim of this study was to investigate the feasibility of this novel automatic catheterization device.This study was performed using 4 fresh cadavers. First, 400 mL of normal saline was filled into the cadaver bladder. Then, the catheter was inserted using the newly developed device. The catheter insertion was performed 3 times for each cadaver, with the penis positioned at 45°, 90°, and 135°, respectively. A transrectal ultrasonography was performed during the catheterization. We evaluated whether the catheter was successfully inserted into the bladder at each position of penis and whether the urethrovesical junction was injured when inserting the catheter. We also measured the volume of normal saline evacuated from the bladder after successful catheterization.With the penis positioned at 45° and 90°, catheter insertion was successful without any damage to the urethrovesical junction. However, when the penis was at 135°, the catheter could not be inserted into the bladder. When the automatic catheter insertion was successful, the bladder was successfully emptied. On average, 81.56 ± 3.26% of normal saline was discharged from the bladder and 11.13 ± 2.09% was remained.The newly developed automatic urinary catheterization device could insert the catheter effectively and safely. This device would be a useful tool for the urinary catheterization of bladder dysfunction patients with upper extremity disability.

Urinary tract infections and bladder management over the first year after discharge from inpatient rehabilitation

Study Design

Secondary analysis of data from a prospective clinical trial of telephone counseling.

Objectives

To describe changes in bladder management and development of bladder-related complications in the first year after discharge from inpatient spinal cord injury (SCI) rehabilitation. To determine whether urinary tract infection (UTI) is associated with bladder management technique or severity of SCI during this time period.

Setting

One SCI Model System center.

Methods

Post hoc analysis of bladder-specific responses to a phone intervention meant to reduce secondary complications of paralysis in adults (n = 169) over the first year after discharge from initial inpatient rehabilitation (IR).

Results

Bladder management was associated with injury level during and immediately after inpatient rehabilitation, and with American Spinal Injury Association (ASIA) Impairment Scale (AIS) score over the entire year. During one year of follow-up, 19% of patients changed bladder management techniques. Among participants performing intermittent catheterization (IC), 20% had urinary incontinence weekly or more frequently. The cumulative incidence of UTI was 71% by the end of the study, and between 27 and 46% of subjects reported UTIs during each 3-month period. Subjects with spontaneous voiding reported significantly fewer UTIs than those using IC or indwelling catheterization (IDC), but there was no significant difference in UTIs between IC and IDC.

Conclusion

During the first year following discharge, approximately one in five patients changed the bladder management technique and urinary incontinence occurred in a substantial proportion of those performing IC. These findings suggest a need for more frequent monitoring of bladder changes and complications over the first year after IR.

Preserved Adrenal Function After Lumbar Spinal Cord Transection Augments Low Pressure Bladder Activity in the Rat

Spinal cord injury (SCI) disconnects supraspinal micturition centers from the lower urinary tract resulting in immediate and long-term changes in bladder structure and function. While cervical and high thoracic SCI have a greater range of systemic effects, clinical data suggest that those with lower (suprasacral) injuries develop poorer bladder outcomes. Here we assess the impact of SCI level on acute changes in bladder activity. We used two SCI models, T3 and L2 complete transections in male Wistar rats, and compared bladder pressure fluctuations to those of naïve and bladder-denervated animals. By 2 days after L2 transection, but not T3 transection or bladder denervation, small amplitude rhythmic contractions (1 mmHg, 0.06 Hz) were present at low intravesical pressures (<6 mmHg); these were still present 1 month following injury, and at 3 months, bladders from L2 SCI animals were significantly larger than those from T3 SCI or naïve animals. Low-pressure contractions were unaffected by blocking ganglionic signaling or bladder denervation at the time of measurements. L2 (and sham surgery) but not T3 transection preserves supraspinal adrenal control, and by ELISA we show lower plasma adrenal catecholamine concentration in the latter. When an adrenalectomy preceded the L2 transection, the aberrant low-pressure contractions more closely resembled those after T3 transection, indicating that the increased bladder activity after lumbar SCI is mediated by preserved adrenal function. Since ongoing low-pressure contractions may condition the detrusor and exacerbate detrusor-sphincter dyssynergia, moderating bladder catecholamine signaling may be a clinically viable intervention strategy.

Nerve growth factor-dependent hyperexcitability of capsaicin-sensitive bladder afferent neurones in mice with spinal cord injury

NEW FINDINGS

What is the central question of this study? Nerve growth factor (NGF) is reportedly a mediator inducing urinary bladder dysfunction. Is NGF directly involved in hyperexcitability of capsaicin-sensitive C-fibre bladder afferent pathways after spinal cord injury (SCI)? What is the main finding and its importance? Neutralization of NGF by anti-NGF antibody treatment reversed the SCI-induced increase in the number of action potentials and the reduction in spike thresholds and A-type K⁺ current density in mouse capsaicin-sensitive bladder afferent neurones. Thus, NGF plays an important and direct role in hyperexcitability of capsaicin-sensitive C-fibre bladder afferent neurones attributable to the reduction in A-type K⁺ channel activity in SCI.

ABSTRACT

Nerve growth factor (NGF) has been implicated as an important mediator in the induction of C-fibre bladder afferent hyperexcitability, which contributes to the emergence of neurogenic lower urinary tract dysfunction after spinal cord injury (SCI). In this study, we determined whether NGF immunoneutralization using an anti-NGF antibody (NGF-Ab) normalizes the SCI-induced changes in electrophysiological properties of capsaicin-sensitive C-fibre bladder afferent neurones in female C57BL/6 mice. The spinal cord was transected at the Th8/Th9 level. Two weeks later, continuous administration of NGF-Ab (10 μg kg^-1  h^-1 , s.c. for 2 weeks) was started. Bladder afferent neurones were labelled with Fast-Blue (FB), a fluorescent retrograde tracer, injected into the bladder wall 3 weeks after SCI. Four weeks after SCI, freshly dissociated L6-S1 dorsal root ganglion neurones were prepared. Whole-cell patch-clamp recordings were then performed in FB-labelled neurones. After recording action potentials or voltage-gated K⁺ currents, the sensitivity of each neurone to capsaicin was evaluated. In capsaicin-sensitive FB-labelled neurones, SCI significantly reduced the spike threshold and increased the number of action potentials during membrane depolarization for 800 ms. These SCI-induced changes were reversed by NGF-Ab. Densities of slow-decaying A-type K⁺ (K_A ) and sustained delayed rectifier-type K⁺ currents were significantly reduced by SCI. The NGF-Ab treatment reversed the SCI-induced reduction in the K_A current density. These results indicate that NGF plays an important role in hyperexcitability of mouse capsaicin-sensitive C-fibre bladder afferent neurones attributable to a reduction in K_A channel activity. Thus, NGF-targeting therapies could be effective for treatment of afferent hyperexcitability and neurogenic lower urinary tract dysfunction after SCI.

Inosine attenuates spontaneous activity in the rat neurogenic bladder through an A2B pathway

Neurogenic detrusor overactivity (NDO) is among the most challenging complications of spinal cord injury (SCI). A recent report by us demonstrated an improvement in NDO in SCI rats following chronic systemic treatment with the purine nucleoside inosine. The objective of this study was to investigate the mechanism of action of inosine underlying improvement of NDO. Male Sprague-Dawley rats underwent complete spinal cord transection at T8. Inosine (1 mM) delivered intravesically to SCI rats during conscious cystometry significantly decreased the frequency of spontaneous non-voiding contractions. In isolated tissue assays, inosine (1 mM) significantly decreased the amplitude of spontaneous activity (SA) in SCI bladder muscle strips. This effect was prevented by a pan-adenosine receptor antagonist CGS15943, but not by A₁ or A₃ receptor antagonists. The A_2A antagonist ZM241385 and A_2B antagonist PSB603 prevented the effect of inosine. The effect of inosine was mimicked by the adenosine receptor agonist NECA and the A_2B receptor agonist BAY60-6583. The inhibition of SA by inosine was not observed in the presence of the BK antagonist, iberiotoxin, but persisted in the presence of K_ATP and SK antagonists. These findings demonstrate that inosine acts via an A_2B receptor-mediated pathway that impinges on specific potassium channel effectors.

Effect of imidafenacin on the urodynamic parameters of patients with indwelling bladder catheters due to spinal cord injury

STUDY DESIGN

A retrospective study.

OBJECTIVES

To investigate the effect of imidafenacin on the urodynamic parameters of patients with indwelling bladder catheters due to spinal cord injury (SCI).

SETTING

Spinal center (Tokyo, Japan).

METHODS

Imidafenacin was prescribed to 34 patients with SCI who had a low cystometric volume and/or detrusor compliance according to a urodynamic study. A low cystometric volume and detrusor compliance were defined as <200 ml and <20 ml cm-1 H2O, respectively. The urodynamic study was repeated 4 weeks after imidafenacin was prescribed. When the urodynamic parameters did not improve in the follow-up study, the dose of imidafenacin was increased twofold. Then the urodynamic study was repeated 4 weeks thereafter. We compared the urodynamic parameters before and after imidafenacin treatment. Complications such as vesico-urethral reflux (VUR) and autonomic dysreflexia (AD) were documented.

RESULTS

Fifteen patients took 0.2 mg of imidafenacin daily, and 19 received 0.4 mg of imidafenacin daily. Imidafenacin increased the cystometric volume from 246.0 to 321.5 ml (median, P=0.002), detrusor compliance from 6.67 ml cm-1 H2O to 8.98 ml cm-1 H2O (median, P=0.012), and decreased the detrusor pressure from 37.0 cm H2O to 30.5 cm H2O (median, P=0.056). All three patients who had VUR fully recovered. Although 3 of 12 patients recovered from AD, 3 patients newly developed symptoms of AD. No patient withdrew from treatment due to adverse effects.

CONCLUSION

Imidafenacin is a safe drug that may improve the urodynamic parameters of patients with SCI, and it possibly alleviates bladder complications.

Continuous use of intermittent bladder catheterization--can social support contribute?

Objective

to investigate the factors affecting the adequate continuous use of intermittent catheterization and its relation with social support.

Method

sectional, descriptive and correlational study involving 49 patients with neuropathic bladder caused by spinal cord injury.

Results

almost all (92%) participants continued the intermittent catheterization, but 46.9% made some changes in the technique. The complications (28.6% of the sample) were mainly infection and vesicolithiasis. There were high scores for social support in relation to people that were part of the patient's social support.

Conclusion

All of them noticed great support from the family, but not from the society in general. The difficulties were related to the lack of equipment and inadequate infrastructure, leading to changes that increased urologic complications.

Longitudinal cleavage of the penis in chronic spinal cord injury: two case reports

CONTEXT

Penile cleavage is a rare complication of spinal cord injury (SCI) in patients with a chronic indwelling catheter. We report two cases of chronic SCI who developed penile urethral cleavage after prolonged use of an indwelling catheter for bladder management.

FINDINGS

A 25-year-old wheelchair mobile male with T7 American Spinal Injury Association (ASIA) Impairment Scale (AIS) grade A paraplegia developed a 4 × 1.5 cm ventral urethral cleavage after using an indwelling catheter for four months with inadequate care. He had an associated urinary tract infection and undiagnosed diabetes mellitus. A suprapubic catheter was inserted and surgical repair recommended after resolution of UTI and adequate control of his diabetes mellitus. After initial treatment he was lost to follow-up. The second patient was a 15-year-old male with AIS grade B tetraplegia who presented with a 2.5 cm cleavage on the ventral aspect of penis for the preceding three months. He had been using an indwelling catheter for bladder management for the previous 18 months. He had modified Ashworth scale grade III spasticity in lower limbs resistant to conservative management. There was no history of trauma, infection or diabetes mellitus. The patient was advised penile urethral repair surgery but was lost to follow-up.

CONCLUSION

Penile cleavage is a rare complication of neurogenic bladder in SCI patients. Patients and care givers should be trained in proper bladder management techniques during the hospital stay, counseled regarding the need for regular follow up, and be taught identification and prevention of common complications.

Neural reconstruction methods of restoring bladder function

During the past century, diverse studies have focused on the development of surgical strategies to restore function of a decentralized bladder after spinal cord or spinal root injury via repair of the original roots or by transferring new axonal sources. The techniques included end-to-end sacral root repairs, transfer of roots from other spinal segments to sacral roots, transfer of intercostal nerves to sacral roots, transfer of various somatic nerves to the pelvic or pudendal nerve, direct reinnervation of the detrusor muscle, or creation of an artificial reflex pathway between the skin and the bladder via the central nervous system. All of these surgical techniques have demonstrated specific strengths and limitations. The findings made to date already indicate appropriate patient populations for each procedure, but a comprehensive assessment of the effectiveness of each technique to restore urinary function after bladder decentralization is required to guide future research and potential clinical application.

Patients With Neurogenic Lower Urinary Tract Dysfunction Following Spinal Cord Injury Are at Increased Risk of Developing Type 2 Diabetes Mellitus: A Population-Based Cohort Study

To investigate whether patients with neurogenic lower urinary tract dysfunction (NLUTD) following spinal cord injury (SCI) are at increased risk of developing type 2 diabetes mellitus (T2DM).The retrospective cohort study used a subset of the Taiwan National Health Insurance Research Database (NHIRD) comprising information on 2 million beneficiaries randomly sampled from the general population. A total of 3515 patients with newly diagnosed SCI were identified during the period of 2001 to 2008. Among them, 170 developed NLUTD following SCI. The control group was consisted of 656 patients without NLUTD over the study period randomly selected by matching NLUTD cases on the date of NLUTD incidence, age, sex, and duration since diagnosis of SCI. The study groups were then followed to the end of 2009. T2DM was the end-point.The incidence rate ratios of T2DM were higher in the NLUTD group than in the control group (4.94 vs. 2.61 per 10,000 person-years), representing an adjusted hazard ratio (AHR) of 1.70 (95% confidence interval [CI] 1.11-2.61). Age-specific AHR was significantly elevated only in patients aged > = 60 years (AHR = 2.52 (95% CI 1.35-4.70)).This study showed that the NLUTD following SCI may significantly increase the risk of developing T2DM.

Urinary catheters: history, current status, adverse events and research agenda

For more than 3500 years, urinary catheters have been used to drain the bladder when it fails to empty. For people with impaired bladder function and for whom the method is feasible, clean intermittent self-catheterization is the optimal procedure. For those who require an indwelling catheter, whether short- or long-term, the self-retaining Foley catheter is invariably used, as it has been since its introduction nearly 80 years ago, despite the fact that this catheter can cause bacterial colonization, recurrent and chronic infections, bladder stones and septicaemia, damage to the kidneys, the bladder and the urethra, and contribute to the development of antibiotic resistance. In terms of medical, social and economic resources, the burden of urinary retention and incontinence, aggravated by the use of the Foley catheter, is huge. In the UK, the harm resulting from the use of the Foley catheter costs the National Health Service between £1.0-2.5 billion and accounts for ∼2100 deaths per year. Therefore, there is an urgent need for the development of an alternative indwelling catheter system. The research agenda is for the new catheter to be easy and safe to insert, either urethrally or suprapubically, to be retained reliably in the bladder and to be withdrawn easily and safely when necessary, to mimic natural physiology by filling at low pressure and emptying completely without damage to the bladder, and to have control mechanisms appropriate for all users.

Neurogenic Bladder and Urodynamic Outcomes in Patients with Spinal Cord Myelopathy

BACKGROUND

Urodynamics (UDs) are routine in traumatic spinal cord injury (SCI), but there are few reports regarding nontraumatic spinal cord myelopathy (SCM) patients.

PURPOSE

To describe the neurogenic bladder and UD outcomes in SCM patients and determine whether the UD recommendations result in clinically important changes to bladder management.

METHODS

This retrospective case study examined a series of SCM patients admitted to a spinal rehabilitation service who underwent UDs between January 1, 2000 and June 30, 2010.

RESULTS

Sixty-five UD tests were performed a median of 7 months post SCM. Most (n = 34; 57%) patients were male, and the median age was 60 years. Most patients (n = 46; 77%) were paraplegic and were continent of urine (n = 38; 58%). Thirty-five (46%) patients voided on sensation, 26 (40%) performed intermittent self-catheterization, and 9 (14%) had an indwelling catheter. The most common UD finding was overactive detrusor with no dysynergia (n = 31; 48%), followed by overactive detrusor with sphincter dysynergia (n = 16; 25%) and detrusor areflexia/underactive (n = 12; 18%). Key UD findings were median cystometric capacity 414 mL (interquartile range [IQR], 300-590), median maximum detrusor contraction 49.5 cmH2O (IQR, 25-85), and median residual volume post voiding 100 mL (IQR, 5-200). The recommendations for changes to bladder management following UDs resulted in clinically important changes to existing strategies in 57 studies (88%).

CONCLUSIONS

Future studies should ascertain whether our screening protocol is appropriate, and a longer-term follow-up should examine the relationship between UD recommendations and prevention of complications.

Improving Outcomes in Patients With Refractory Idiopathic and Neurogenic Detrusor Overactivity: Management Strategies

Neurogenic detrusor overactivity (NDO) is a lower urinary tract dysfunction commonly seen in rehabilitation settings. The emotional, medical, and financial consequences of NDO can be substantial and management typically requires a multidisciplinary team approach. Physiatrists need to be able to identify patients who require referral to specialists for diagnostic testing or higher-tiered treatment and need to engender open lines of communication between their patients and all treating clinicians. This requires an understanding of the evaluation, diagnosis, and treatment of neurogenic lower urinary tract dysfunctions.

An unresolved relationship: the relationship between lesion severity and neurogenic bladder in patients with spinal cord injury

OBJECTIVES

We aimed to investigate the relationship between the severity of the spinal lesion and urodynamic findings, bladder drainage method at discharge, and incidence of renal calculi in patients with spinal cord injury (SCI). STUDYDESIGN: Retrospective.

SETTING

In-patient rehabilitation unit of a tertiary research hospital.

METHODS

A total of 131 patients who were admitted to our clinic with a diagnosis of SCI and placed into a rehabilitation program were included in the study. The severity of the lesion was determined according to the American Spinal Injury Association Impairment Scale (AIS). We evaluated the relationship between the severity of the lesion and the detrusor hyperactivity and compliance as determined by urodynamic investigation, the bladder drainage method used at discharge, and the renal calculi rate as determined by ultrasonography.

RESULTS

While no difference was found between the patients with complete and incomplete injuries in terms of age, sex, disease duration, detrusor hyperactivity and compliance, the bladder drainage method was found to show a significant change according to the severity of the lesion. None of the patients were found to have hydronephrosis and the rate of renal calculi showed no statistically significant difference according to the severity of the lesion.

CONCLUSIONS

We concluded that urodynamic examination is required in each patient with SCI as the severity of the lesion is not sufficient to determine the bladder type, and patients with complete and incomplete injuries should be monitored with the same sensitivity in terms of complications.

Repetitive Treatment with Diluted Bee Venom Attenuates the Induction of Below-Level Neuropathic Pain Behaviors in a Rat Spinal Cord Injury Model

The administration of diluted bee venom (DBV) into an acupuncture point has been utilized traditionally in Eastern medicine to treat chronic pain. We demonstrated previously that DBV has a potent anti-nociceptive efficacy in several rodent pain models. The present study was designed to examine the potential anti-nociceptive effect of repetitive DBV treatment in the development of below-level neuropathic pain in spinal cord injury (SCI) rats. DBV was applied into the Joksamli acupoint during the induction and maintenance phase following thoracic 13 (T13) spinal hemisection. We examined the effect of repetitive DBV stimulation on SCI-induced bilateral pain behaviors, glia expression and motor function recovery. Repetitive DBV stimulation during the induction period, but not the maintenance, suppressed pain behavior in the ipsilateral hind paw. Moreover, SCI-induced increase in spinal glia expression was also suppressed by repetitive DBV treatment in the ipsilateral dorsal spinal cord. Finally, DBV injection facilitated motor function recovery as indicated by the Basso–Beattie–Bresnahan rating score. These results indicate that the repetitive application of DBV during the induction phase not only decreased neuropathic pain behavior and glia expression, but also enhanced locomotor functional recovery after SCI. This study suggests that DBV acupuncture can be a potential clinical therapy for SCI management.

Urodynamic patterns after traumatic spinal cord injury

OBJECTIVES

To study the correlation between neurological level of spinal injury and bladder functions as detected by urodynamic study.

STUDY DESIGN

Analytical study.

SETTING AND PARTICIPANTS

Seventy individuals with traumatic spinal cord injury (SCI) admitted to the Department of Physical Medicine and Rehabilitation, S.M.S. Medical College and Hospital, Jaipur. Detailed clinical, neurological evaluation as per American Spinal Injury Association Classification and radiological assessment were done along with clinical examination of bladder and urodynamic study.

RESULTS

Out of 65 patients with suprasacral injuries, 53 (81.5%) demonstrated hyperreflexia with or without detrusor sphincter dyssynergia, 6 (9.2%) detrusor areflexia, and 6 (9.2%) had normal bladders, 41 (59.4%) low compliance (<20 ml/cmH2O), and 47 (72.30%) had high detrusor leak pint pressures (>40 cmH2O). Of the five patients with sacral injuries, one (20%) showed detrusor hyperreflexia, four (80%) detrusor areflexia, and one (20%) had low bladder compliance; all five (100%) had high detrusor leak point pressures.

CONCLUSIONS

The correlation between somatic neurologic findings, spinal imaging studies, and urodynamic findings in patients with SCI is not exact. Therefore, bladder management should not completely rely only on clinical bladder evaluation or neurological examination alone, but should always include urodynamic studies.

Development of hydronephrosis secondary to poorly managed neurogenic bowel requiring surgical disimpaction in a patient with spinal cord injury: a case report

CONTEXT

Case of an adult patient with paraplegia managing neurogenic bladder with intermittent catheterization who was not performing a standard bowel program for management of neurogenic bowel.

FINDINGS

Patient presented with increasing spasticity, fecal incontinence, and abdominal pain and ultimately was hospitalized for management. Imaging revealed massive fecal impaction, resulting in ureteral obstruction and hydronephrosis. Despite repeated aggressive bowel regimens, serial abdominal X-rays showed continued large stool burden. Ultimately surgical intervention was required to evacuate the colon and subsequently the hydronephrosis resolved.

CONCLUSION/CLINICAL RELEVANCE

This case illustrates the importance of proper management of neurogenic bowel, as significant medical complications, such as hydronephrosis can occur with poorly managed neurogenic bowel.

Electroacupuncture at points Baliao and Huiyang (BL35) for post-stroke detrusor overactivity

Acupuncture is used extensively in China for the treatment of stroke and other neurological disorders. The National Institutes of Health recommends acupuncture as an adjunctive therapy for stroke recovery. This study included patients with post-stroke detrusor overactivity who were treated in the Department of Neurology, Fourth Hospital of Harbin Medical University, China. Subjects received either electroacupuncture or sham electroacupuncture at points Baliao [including bilateral Shangliao (BL31), bilateral Ciliao (BL32), bilateral Zhongliao (BL33), and bilateral Xialiao (BL34)] and Huiyang (BL35). Our results showed that electroacupuncture significantly improved cystometric capacity and bladder compliance, decreased detrusor leak point pressure, ameliorated lower urinary tract symptoms, and decreased the risk of upper urinary tract damage. These findings indicate that electroacupuncture at points Baliao and Huiyang is an effective treatment for post-stroke detrusor overactivity.

Bladder reinnervation using a primarily motor donor nerve (femoral nerve branches) is functionally superior to using a primarily sensory donor nerve (genitofemoral nerve)

PURPOSE

We determined whether transfer of a primarily motor nerve (femoral) to the anterior vesicle branch of the pelvic nerve would allow for more effective bladder reinnervation than transfer of a primarily sensory nerve (genitofemoral).

MATERIALS AND METHODS

A total of 41 female mongrel dogs underwent bladder decentralization and then bilateral nerve transfer, or served as sham operated or unoperated controls. Decentralization was achieved by bilateral transection of all sacral roots that induced bladder contraction upon electrical stimulation. Retrograde neuronal labeling dye was injected in the bladder 3 weeks before sacrifice.

RESULTS

Increased detrusor pressure after direct stimulation of the transferred nerve, lumbar spinal cord or spinal root was observed in 12 of 17 dogs with genitofemoral nerve transfer and in 9 of 10 with femoral nerve transfer (mean ± SEM 7.6 ± 1.4 and 11.7 ± 3.1 cm H2O, respectively). Mean detrusor pressure after direct electrical stimulation of transferred femoral nerves was statistically significantly greater than after stimulation of transferred genitofemoral nerves. Retrograde labeled neurons from the bladder observed in upper lumbar cord segments after genitofemoral and femoral nerve transfer confirmed bladder reinnervation, as did labeled axons at the nerve transfer site.

CONCLUSIONS

While transfer of a mixed sensory and motor nerve (genitofemoral) or a primarily motor nerve (femoral) can reinnervate the bladder, using the primarily motor nerve provided greater return of nerve evoked detrusor contraction. This surgical approach may be useful to achieve bladder emptying in patients with lower motor spinal cord injury.

Use of autologous mesenchymal stem cells derived from bone marrow for the treatment of naturally injured spinal cord in dogs

The use of stem cells in injury repair has been extensively investigated. Here, we examined the therapeutic effects of autologous bone marrow mesenchymal stem cells (MSC) transplantation in four dogs with natural traumatic spinal cord injuries. MSC were cultured in vitro, and proliferation rate and cell viability were evaluated. Cell suspensions were prepared and surgically administered into the spinal cord. The animals were clinically evaluated and examined by nuclear magnetic resonance. Ten days after the surgical procedure and MSC transplantation, we observed a progressive recovery of the panniculus reflex and diminished superficial and deep pain response, although there were still low proprioceptive reflexes in addition to a hyperreflex in the ataxic hind limb movement responses. Each dog demonstrated an improvement in these gains over time. Conscious reflex recovery occurred simultaneously with moderate improvement in intestine and urinary bladder functions in two of the four dogs. By the 18th month of clinical monitoring, we observed a remarkable clinical amelioration accompanied by improved movement, in three of the four dogs. However, no clinical gain was associated with alterations in magnetic resonance imaging. Our results indicate that MSC are potential candidates for the stem cell therapy following spinal cord injury.